Publications by authors named "Georg Salomon"

120 Publications

A systematic review and meta-analysis of Histoscanning™ in prostate cancer diagnostics.

World J Urol 2021 Apr 7. Epub 2021 Apr 7.

Institute for Urology and Reproductive Health, Sechenov University, Bolshaya Pirogovskaya str. 2 bld. 1, Moscow, 119991, Russia.

Context: The value of Histoscanning™ (HS) in prostate cancer (PCa) imaging is much debated, although it has been used in clinical practice for more than 10 years now.

Objective: To summarize the data on HS from various PCa diagnostic perspectives to determine its potential.

Materials And Methods: We performed a systematic search using 2 databases (Medline and Scopus) on the query "Histoscan*". The primary endpoint was HS accuracy. The secondary endpoints were: correlation of lesion volume by HS and histology, ability of HS to predict extracapsular extension or seminal vesicle invasion.

Results: HS improved cancer detection rate "per core", OR = 16.37 (95% CI 13.2; 20.3), p < 0.0001, I = 98% and "per patient", OR = 1.83 (95% CI 1.51; 2.21), p < 0.0001, I = 95%. The pooled accuracy was markedly low: sensitivity - 0.2 (95% CI 0.19-0.21), specificity - 0.12 (0.11-0.13), AUC 0.12. 8 of 10 studiers showed no additional value for HS. The pooled accuracy with histology after RP was relatively better, yet still very low: sensitivity - 0.56 (95% CI 0.5-0.63), specificity - 0.23 (0.18-0.28), AUC 0.4. 9 of 12 studies did not show any benefit of HS.

Conclusion: This meta-analysis does not see the incremental value in comparing prostate Histoscanning with conventional TRUS in prostate cancer screening and targeted biopsy. HS proved to be slightly more accurate in predicting extracapsular extension on RP, but the available data does not allow us to draw any conclusions on its effectiveness in practice. Histoscanning is a modification of ultrasound for prostate cancer visualization. The available data suggest its low accuracy in screening and detecting of prostate cancer.
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http://dx.doi.org/10.1007/s00345-021-03684-8DOI Listing
April 2021

Impact of Sarcopenia on Functional and Oncological Outcomes After Radical Prostatectomy.

Front Surg 2020 3;7:620714. Epub 2021 Feb 3.

Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany.

Knowledge about the significance of sarcopenia (muscle loss) in prostate cancer (PCa) patients is limited. The aim of this study was to determine the influence of skeletal muscle index (SMI) on early functional and pathological outcome in patients undergoing radical prostatectomy (RP). One hundred randomly chosen patients who received RP between November 2016 and April 2017 at Martini-Klinik (Hamburg, Germany) were retrospectively assessed. SMI (skeletal muscle mass cross-sectional area at L3/m) was measured by preoperative staging computed tomography scans at L3 level. Cox regression analysis was applied to determine the impact of SMI on post-operative outcome. Follow-up was 12 months. Continence was defined as no more than one safety pad per day. Mean age of the cohort was 63.6 years. Mean SMI was 54.06 cm/m (range, 40.65-74.58 cm/m). Of the patients, 41.4% had pT2, 28.7% had pT3a, and 29.9% had pT3b or pT4 PCa. SMI revealed to be without significant correlation on tumor stage. Follow-up data of 55 patients were available for early functional outcome analysis. SMI showed no significant influence on erectile function in multivariable Cox regression analysis. In multivariable Cox regression analysis, SMI turned out to have no influence on continence rates 6 weeks after surgery. The present study shows that patients undergoing RP have a wide range of SMI. Unlike in other urological malignancies, there was no significant impact of SMI on early functional outcome and pathological outcome. A larger cohort is needed to confirm these results.
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http://dx.doi.org/10.3389/fsurg.2020.620714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887284PMC
February 2021

Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence after Radiation Therapy and Radical Prostatectomy.

Eur Urol Oncol 2021 Feb 10. Epub 2021 Feb 10.

Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands.

Background: Imaging techniques are used to identify local recurrence of prostate cancer (PCa) for salvage therapy and to exclude metastases that should be addressed with systemic therapy. For magnetic resonance imaging (MRI), a reduction in the variability of acquisition, interpretation, and reporting is required to detect local PCa recurrence in men with biochemical relapse after local treatment with curative intent.

Objective: To propose a standardised method for image acquisition and assessment of PCa local recurrence using MRI after radiation therapy (RP) and radical prostatectomy (RT).

Evidence Acquisition: Prostate Imaging for Recurrence Reporting (PI-RR) was formulated using the existing literature. An international panel of experts conducted a nonsystematic review of the literature. The PI-RR system was created via consensus through a combination of face-to-face and online discussions.

Evidence Synthesis: Similar to with PI-RADS, based on the best available evidence and expert opinion, the minimum acceptable MRI parameters for detection of recurrence after radiation therapy and radical prostatectomy are set. Also, a simplified and standardised terminology and content of the reports that use five assessment categories to summarise the suspicion of local recurrence (PI-RR) are designed. PI-RR scores of 1 and 2 are assigned to lesions with a very low and low likelihood of recurrence, respectively. PI-RR 3 is assigned if the presence of recurrence is uncertain. PI-RR 4 and 5 are assigned for a high and very high likelihood of recurrence, respectively. PI-RR is intended to be used in routine clinical practice and to facilitate data collection and outcome monitoring for research.

Conclusions: This paper provides a structured reporting system (PI-RR) for MRI evaluation of local recurrence of PCa after RT and RP.

Patient Summary: A new method called PI-RR was developed to promote standardisation and reduce variations in the acquisition, interpretation, and reporting of magnetic resonance imaging for evaluating local recurrence of prostate cancer and guiding therapy.
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http://dx.doi.org/10.1016/j.euo.2021.01.003DOI Listing
February 2021

A systematic review of nerve-sparing surgery for high-risk prostate cancer.

Minerva Urol Nefrol 2021 Jan 13. Epub 2021 Jan 13.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Background: We provide a systematic analysis of NSS to assess and summarize the risks and benefits of NSS in high-risk PCa.

Methods: We have undertaken a systematic search of original articles at 3 databases (Medline (PubMed), Scopus, and Web of Science). Original articles in English containing outcomes of nerve-sparing RP for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: EF and urinary continence.

Results: The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on OR for positive margin and biochemical relapse. The presented results showed no effect of NS on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (HR=0.93, 0.52 1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with or without NSS.

Conclusions: NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.
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http://dx.doi.org/10.23736/S0393-2249.20.04178-8DOI Listing
January 2021

Molecular biomarkers in the context of focal therapy for prostate cancer: recommendations of a Delphi Consensus from the Focal Therapy Society.

Minerva Urol Nefrol 2021 01 13. Epub 2021 Jan 13.

Department of Urology, Institut Mutualiste Montsouris, Paris, France.

Background: Focal Therapy (FT) for Prostate Cancer (PCa) is promising. However, long-term oncological results are awaited and there is no consensus on follow-up strategies. Molecular biomarkers (MB) may be useful in selecting, treating and following up men undergoing FT, though there is limited evidence in this field to guide practice. We aimed to conduct a consensus meeting, endorsed by the Focal Therapy Society, amongst a large group of experts, to understand the potential utility of MB in FT for localised PCa.

Materials And Methods: A 38-item questionnaire was built following a literature search. The authors then performed three rounds of a Delphi Consensus using DelphiManager, using the GRADE grid scoring system, followed by a face-to-face expert meeting. Three areas of interest were identified and covered concerning MB for FT, i) the current/present role; ii) the potential/future role; iii) the recommended features for future studies. Consensus was defined using a 70% agreement threshold.

Results: Of 95 invited experts, 42 (44.2%) completed the three Delphi rounds. Twenty-four items reached a consensus and they were then approved at the meeting involving (n=15) experts. Fourteen items reached a consensus on uncertainty, or they did not reach a consensus. They were re-discussed, resulting in a consensus (n=3), a consensus on a partial agreement (n=1), and a consensus on uncertainty (n=10). A final list of statements were derived from the approved and discussed items, with the addition of three generated statements, to provide guidance regarding MB in the context of FT for localised PCa. Research efforts in this field should be considered a priority.

Conclusions: The present study detailed an initial consensus on the use of MB in FT for PCa. This is until evidence becomes available on the subject.
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http://dx.doi.org/10.23736/S0393-2249.20.04160-0DOI Listing
January 2021

Moving away from systematic biopsies: image-guided prostate biopsy (in-bore biopsy, cognitive fusion biopsy, MRUS fusion biopsy) -literature review.

World J Urol 2021 Mar 29;39(3):677-686. Epub 2020 Jul 29.

Department of Urology, Istanbul Medipol University, Istanbul, Turkey.

Objective: To compare the detection rate of clinically significant cancer (CSCa) by magnetic resonance imaging-targeted biopsy (MRI-TB) with that by standard systematic biopsy (SB) and to evaluate the role of MRI-TB as a replacement from SB in men at clinical risk of prostate cancer.

Methods: The non-systematic literature was searched for peer-reviewed English-language articles using PubMed, including the prospective paired studies, where the index test was MRI-TB and the comparator text was SB. Also the randomized clinical trials (RCTs) are included if one arm was MRI-TB and another arm was SB.

Results: Eighteen prospective studies used both MRI-TB and TRUS-SB, and eight RCT received one of the tests for prostate cancer detection. In most prospective trials to compare MRI-TB vs. SB, there was no significant difference in any cancer detection rate; however, MRI-TB detected more men with CSCa and fewer men with CISCa than SB.

Conclusion: MRI-TB is superior to SB in detection of CSCa. Since some significant cancer was detected by SB only, a combination of SB with the TB technique would avoid the underdiagnosis of CSCa.
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http://dx.doi.org/10.1007/s00345-020-03366-xDOI Listing
March 2021

ESUR/ESUI consensus statements on multi-parametric MRI for the detection of clinically significant prostate cancer: quality requirements for image acquisition, interpretation and radiologists' training.

Eur Radiol 2020 Oct 19;30(10):5404-5416. Epub 2020 May 19.

Department of Radiology & Nuclear Medicine and Anatomy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.

Objectives: This study aims to define consensus-based criteria for acquiring and reporting prostate MRI and establishing prerequisites for image quality.

Methods: A total of 44 leading urologists and urogenital radiologists who are experts in prostate cancer imaging from the European Society of Urogenital Radiology (ESUR) and EAU Section of Urologic Imaging (ESUI) participated in a Delphi consensus process. Panellists completed two rounds of questionnaires with 55 items under three headings: image quality assessment, interpretation and reporting, and radiologists' experience plus training centres. Of 55 questions, 31 were rated for agreement on a 9-point scale, and 24 were multiple-choice or open. For agreement items, there was consensus agreement with an agreement ≥ 70% (score 7-9) and disagreement of ≤ 15% of the panellists. For the other questions, a consensus was considered with ≥ 50% of votes.

Results: Twenty-four out of 31 of agreement items and 11/16 of other questions reached consensus. Agreement statements were (1) reporting of image quality should be performed and implemented into clinical practice; (2) for interpretation performance, radiologists should use self-performance tests with histopathology feedback, compare their interpretation with expert-reading and use external performance assessments; and (3) radiologists must attend theoretical and hands-on courses before interpreting prostate MRI. Limitations are that the results are expert opinions and not based on systematic reviews or meta-analyses. There was no consensus on outcomes statements of prostate MRI assessment as quality marker.

Conclusions: An ESUR and ESUI expert panel showed high agreement (74%) on issues improving prostate MRI quality. Checking and reporting of image quality are mandatory. Prostate radiologists should attend theoretical and hands-on courses, followed by supervised education, and must perform regular performance assessments.

Key Points: • Multi-parametric MRI in the diagnostic pathway of prostate cancer has a well-established upfront role in the recently updated European Association of Urology guideline and American Urological Association recommendations. • Suboptimal image acquisition and reporting at an individual level will result in clinicians losing confidence in the technique and returning to the (non-MRI) systematic biopsy pathway. Therefore, it is crucial to establish quality criteria for the acquisition and reporting of mpMRI. • To ensure high-quality prostate MRI, experts consider checking and reporting of image quality mandatory. Prostate radiologists must attend theoretical and hands-on courses, followed by supervised education, and must perform regular self- and external performance assessments.
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http://dx.doi.org/10.1007/s00330-020-06929-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476997PMC
October 2020

Dual-Energy Computed Tomography for Stone Type Assessment: A Pilot Study of Dual-Energy Computed Tomography with Five Indices.

J Endourol 2020 09 28;34(9):893-899. Epub 2020 May 28.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

To assess the efficacy of dual-energy CT (DECT) in predicting the composition of urinary stones with a single index (dual energy ratio [DER]) and five indices. Patients undergoing DECT before active urolithiasis treatment were prospectively enrolled in the study. Predictions of stone composition were made based on discriminant analysis with a single index (DER) and five indices (stone density at 80 and 135 kV, Zeff [the effective atomic number of the absorbent material] of the stone, DER, dual-energy index [DEI] and dual-energy difference [DED]). After extraction, stone composition was evaluated by means of physicochemical analyses (X-ray phase analysis, electron microscopy, wet chemistry techniques, and infrared spectroscopy). A total of 91 patients were included. For calcium oxalate monohydrate (COM) stones, the sensitivity, specificity, and overall accuracy of DECT with one index (DER) were 83.3%, 89.8%, and 86.8%, respectively; for calcium oxalate dihydrate (COD) and calcium phosphate stones-88.2%, 92.9%, and 91.2%, respectively; for uric acid stones-0%, 98.8% and 97.8%, respectively; for struvite stones-60%, 95.3%, and 93.4%, respectively. Discriminant analysis with five indices yielded the following sensitivity, specificity, and overall accuracy: 95.2%, 89.8%, and 92.3% for COM stones, 85.3%, 96.4%, and 92.3% for COD stones, and 100% in all three categories for both uric acid and struvite stones. DECT is a promising tool for stone composition assessment. It allowed for evaluation of chemical composition of all stone types with specificity and accuracy ranging from 85% to 100%. Five DECT indices have shown much better diagnostic accuracy compared to a single DECT index.
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http://dx.doi.org/10.1089/end.2020.0243DOI Listing
September 2020

Validation of the updated eighth edition of AJCC for prostate cancer: Removal of pT2 substages - Does extent of tumor involvement matter?

Urol Oncol 2020 07 31;38(7):637.e1-637.e7. Epub 2020 Mar 31.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Background: Updates in the eighth edition of the AJCC prostate cancer staging manual include removal of the organ-confined (pT2) substages.

Methods: Retrospective analyses of 12,028 pT2 patients that underwent radical prostatectomy between 2003 and 2016 and did not receive neo- or adjuvant treatments. Kaplan-Meier curves as well as multivariable Cox-regression analyses compared biochemical recurrence (BCR), metastatic progression (MP) and overall mortality (OM) between the 3 subcategories (pT2a, pT2b and pT2c).

Results: After surgery, 1,441 patients were classified as pT2a, 126 as pT2b and 10.495 as pT2c. Five-year BFS rates for pT2a, pT2b and pT2c were 92.0% vs. 97.4% vs. 88.0%. For the same groups, 5-year MP-FS rates were 99.5% vs. 100% vs. 99.0% and 5-year OS rates were 98.0% vs. 98.2% vs. 97.7%. In multivariable analyses pT2 substratification did not reach independent predictor status for biochemical recurrence, MP or overall mortality.

Conclusions: Substratification of pT2 prostate cancer was not predictive for further disease progression. Therefore, removing the substages simplifies the staging system without loss of important information.
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http://dx.doi.org/10.1016/j.urolonc.2020.01.005DOI Listing
July 2020

Factors Influencing Variability in the Performance of Multiparametric Magnetic Resonance Imaging in Detecting Clinically Significant Prostate Cancer: A Systematic Literature Review.

Eur Urol Oncol 2020 04 17;3(2):145-167. Epub 2020 Mar 17.

Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.

Context: There is a lack of comprehensive data regarding the factors that influence the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) to detect and localize clinically significant prostate cancer (csPCa).

Objective: To systematically review the current literature assessing the factors influencing the variability of mpMRI performance in csPCa diagnosis.

Evidence Acquisition: A computerized bibliographic search of Medline/PubMed database was performed for all studies assessing magnetic field strength, use of an endorectal coil, assessment system used by radiologists and inter-reader variability, experience of radiologists and urologists, use of a contrast agent, and use of computer-aided diagnosis (CAD) tools in relation to mpMRI diagnostic accuracy.

Evidence Synthesis: A total of 77 articles were included. Both radiologists' reading experience and urologists'/radiologists' biopsy experience were the main factors that influenced diagnostic accuracy. Therefore, it is mandatory to indicate the experience of the interpreting radiologists and biopsy-performing urologists to support the reliability of the findings. The most recent Prostate Imaging Reporting and Data System (PI-RADS) guidelines are recommended for use as the main assessment system for csPCa, given the simplified and standardized approach as well as its particular added value for less experienced radiologists. Biparametric MRI had similar accuracy to mpMRI; however, biparametric MRI performed better with experienced readers. The limited data available suggest that the combination of CAD and radiologist readings may influence diagnostic accuracy positively.

Conclusions: Multiple factors affect the accuracy of mpMRI and MRI-targeted biopsy to detect and localize csPCa. The high heterogeneity across the studies underlines the need to define the experience of radiologists and urologists, implement quality control, and adhere to the most recent PI-RADS assessment guidelines. Further research is needed to clarify which factors impact the accuracy of the MRI pathway and how.

Patient Summary: We systematically reported the factors influencing the accuracy of multiparametric magnetic resonance imaging (mpMRI) in detecting clinically significant prostate cancer (csPCa). These factors are significantly related to each other, with the experience of the radiologists being the dominating factor. In order to deliver the benefits of mpMRI to diagnose csPCa, it is necessary to develop expertise for both radiologists and urologists, implement quality control, and adhere to the most recent Prostate Imaging Reporting and Data System assessment guidelines.
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http://dx.doi.org/10.1016/j.euo.2020.02.005DOI Listing
April 2020

Current European Trends in Endoscopic Imaging and Transurethral Resection of Bladder Tumors.

J Endourol 2020 03 19;34(3):312-321. Epub 2019 Nov 19.

RaVeNNA 4pi-Consortium of the German Federal Ministry of Education and Research (BMBF), Mannheim, Germany.

The aim of this survey was to obtain an overview of current European standards in the endoscopic visualization and management of bladder tumors. An online survey was launched in July 2018 for a duration of 4 months. It was distributed to all members of the European Association of Urology (EAU) and included 23 questions divided into 3 thematic sections: general information, white light cystoscopy (WLC) and imaging, and transurethral resection of bladder tumor (TURBT) techniques. Responses of 222 participants were included for analysis. The majority of physicians were between 30 and 40 years of age (48.2%,  = 107) and performed over 50 TURBT per year (52.2%,  = 115). Overall, 52.3% ( = 116) reported WLC findings in written form only, 23.8% ( = 53) added endoscopic footage, and 79.2% ( = 176) considered preliminary WLC/TURBT reports before performing a subsequent bladder intervention. About half of the participants (50.5%,  = 104) used additional tumor visualization methods (aTVMs), but aTVMs were utilized by a greater proportion of physicians from Western countries (58.1%,  = 90) compared with developing countries (20.0%,  = 7). Photodynamic diagnosis was the predominant aTVM technique employed (43.8%,  = 60). Bipolar current was the most common technique for TURBT (46.6%,  = 149). Most urologists in this study occasionally utilized techniques like resections in fractions (80%,  = 161) or resection (87.2%,  = 182). A repeated TURBT was performed when no muscle was found in the specimen (70.6%,  = 149) and/or if the tumor was stage pT1 (72.0%,  = 152) or high grade (63.0%,  = 133). Implementation of resection techniques or repeated TURBT within EAU guidelines is promising, but it can be further challenged. For example, WLC/TURBT reporting should be improved since urologists consistently consider previous documentation. Given the moderate application rate of aTVMs, an attempt to increase its utilization would lead to a better assessment of its potential benefit.
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http://dx.doi.org/10.1089/end.2019.0651DOI Listing
March 2020

Automated multiparametric localization of prostate cancer based on B-mode, shear-wave elastography, and contrast-enhanced ultrasound radiomics.

Eur Radiol 2020 Feb 10;30(2):806-815. Epub 2019 Oct 10.

Lab of Biomedical Diagnostics, Department of Electrical Engineering, Eindhoven University of Technology, De Rondom 70, 5612 AP, Eindhoven, The Netherlands.

Objectives: The aim of this study was to assess the potential of machine learning based on B-mode, shear-wave elastography (SWE), and dynamic contrast-enhanced ultrasound (DCE-US) radiomics for the localization of prostate cancer (PCa) lesions using transrectal ultrasound.

Methods: This study was approved by the institutional review board and comprised 50 men with biopsy-confirmed PCa that were referred for radical prostatectomy. Prior to surgery, patients received transrectal ultrasound (TRUS), SWE, and DCE-US for three imaging planes. The images were automatically segmented and registered. First, model-based features related to contrast perfusion and dispersion were extracted from the DCE-US videos. Subsequently, radiomics were retrieved from all modalities. Machine learning was applied through a random forest classification algorithm, using the co-registered histopathology from the radical prostatectomy specimens as a reference to draw benign and malignant regions of interest. To avoid overfitting, the performance of the multiparametric classifier was assessed through leave-one-patient-out cross-validation.

Results: The multiparametric classifier reached a region-wise area under the receiver operating characteristics curve (ROC-AUC) of 0.75 and 0.90 for PCa and Gleason > 3 + 4 significant PCa, respectively, thereby outperforming the best-performing single parameter (i.e., contrast velocity) yielding ROC-AUCs of 0.69 and 0.76, respectively. Machine learning revealed that combinations between perfusion-, dispersion-, and elasticity-related features were favored.

Conclusions: In this paper, technical feasibility of multiparametric machine learning to improve upon single US modalities for the localization of PCa has been demonstrated. Extended datasets for training and testing may establish the clinical value of automatic multiparametric US classification in the early diagnosis of PCa.

Key Points: • Combination of B-mode ultrasound, shear-wave elastography, and contrast ultrasound radiomics through machine learning is technically feasible. • Multiparametric ultrasound demonstrated a higher prostate cancer localization ability than single ultrasound modalities. • Computer-aided multiparametric ultrasound could help clinicians in biopsy targeting.
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http://dx.doi.org/10.1007/s00330-019-06436-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957554PMC
February 2020

Reply by Authors.

J Urol 2019 12 30;202(6):1172-1173. Epub 2019 Aug 30.

Prostate Cancer Center, Martini-Klinik Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

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http://dx.doi.org/10.1097/01.JU.0000581796.73447.deDOI Listing
December 2019

Multiparametric Ultrasound for Prostate Cancer Detection and Localization: Correlation of B-mode, Shear Wave Elastography and Contrast Enhanced Ultrasound with Radical Prostatectomy Specimens.

J Urol 2019 12 27;202(6):1166-1173. Epub 2019 Jun 27.

Prostate Cancer Center, Martini-Klinik Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Purpose: Similar to multiparametric magnetic resonance imaging, multiparametric ultrasound represents a promising approach to prostate cancer imaging. We determined the diagnostic performance of B-mode, shear wave elastography and contrast enhanced ultrasound with quantification software as well as the combination, multiparametric ultrasound, for clinically significant prostate cancer localization using radical prostatectomy histopathology as the reference standard.

Materials And Methods: From May 2017 to July 2017, 50 men with biopsy proven prostate cancer underwent multiparametric ultrasound before radical prostatectomy at 1 center. Three readers independently evaluated 12 anatomical regions of interest for the likelihood of clinically significant prostate cancer on a 5-point Likert scale for all separate ultrasound modalities and multiparametric ultrasound. A logistic linear mixed model was used to estimate diagnostic performance for the localization of clinically significant prostate cancer (any tumor with Gleason score 3 + 4 = 7 or greater, tumor volume 0.5 ml or greater, extraprostatic extension or stage pN1) using a Likert score of 3 or greater and 4 or greater as the threshold. To detect the index lesion the readers selected the 2 most suspicious regions of interest.

Results: A total of 48 men were included in the final analysis. The region of interest specific sensitivity of multiparametric ultrasound (Likert 3 or greater) for clinically significant prostate cancer was 74% (95% CI 67-80) compared to 55% (95% CI 47-63), 55% (95% CI 47-63) and 59% (95% CI 51-67) for B-mode, shear wave elastography and contrast enhanced ultrasound, respectively. Multiparametric ultrasound sensitivity was significantly higher for Likert thresholds and all different clinically significant prostate cancer definitions (all p <0.05). Multiparametric ultrasound improved the detection of index lesion prostate cancer.

Conclusions: Multiparametric ultrasound of the prostate, consisting of B-mode, shear wave elastography and contrast enhanced ultrasound with parametric maps, improved localization and index lesion detection of clinically significant prostate cancer compared to single ultrasound modalities, yielding good sensitivity.
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http://dx.doi.org/10.1097/JU.0000000000000415DOI Listing
December 2019

Enumeration and Changes in Circulating Tumor Cells and Their Prognostic Value in Patients Undergoing Cytoreductive Radical Prostatectomy for Oligometastatic Prostate Cancer-Translational Research Results from the Prospective ProMPT trial.

Eur Urol Focus 2021 Jan 6;7(1):55-62. Epub 2019 Jun 6.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Background: The prognostic value of circulating tumor cells (CTCs) in patients with hormone-naïve oligometastatic prostate cancer (HNoMPC) undergoing cytoreductive radical prostatectomy (CRP) is unknown.

Objective: To determine the pre- and postoperative prognostic value of CTC enumeration in patients undergoing CRP.

Design, Setting, And Participants: Thirty-three patients with HNoMPC from the prospective, single-arm ProMPT trial who underwent CRP between 2014 and 2015 at the Martini-Klinik were evaluated. Follow-up visits for all patients were conducted every 6 mo up to 36 mo after CRP and included serial detection of CTCs in 7.5 ml blood samples using the CellSearch system.

Intervention: CRP.

Outcome Measurements And Statistical Analysis: CTC enumerations before and after CRP, and their prognostic value on metastatic castration-resistant prostate cancer-free survival and overall survival (OS) were analyzed using Kaplan-Meier plots and univariable Cox-regression analysis.

Results And Limitations: Sixteen patients (48.5%) had positive CTCs prior to CRP. A CTC count of ≥2 before or 6 mo after CRP was a prognostic factor for worse oncologic outcome. Compared with other biomarkers (prostate-specific antigen, lactate dehydrogenase, and bone-specific alkaline phosphatase), the prognostic value of CTCs was highest using Harrell's C for OS (0.69), while the highest C-index could be achieved for a combination of conventional markers and CTC count (0.74). After progression to metastatic castration-resistant prostate cancer, CTC enumeration of ≥5 was prognostic for OS. The main limitation is the small sample size.

Conclusions: CTC enumeration contributes to prognostic information, which might help select HNoMPC patients who might benefit most from CRP.

Patient Summary: In this report, we looked at the value of circulating tumor cell (CTC) determination in patients undergoing radical prostatectomy for oligometastatic prostate cancer. We could show that the number of CTCs was a prognostic factor at all analyzed time points and was more closely associated with prognosis than other biomarkers commonly used in daily clinical practice.
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http://dx.doi.org/10.1016/j.euf.2019.05.008DOI Listing
January 2021

Prostate cancer prognosis in men with other malignancies prior to radical prostatectomy.

Urol Oncol 2019 09 30;37(9):575.e1-575.e7. Epub 2019 Apr 30.

Martini-Klinik, Prostate Cancer Center, Medical University Hamburg Eppendorf, Hamburg, Germany. Electronic address:

Objectives: Cancer survivors are often diagnosed with subsequent prostate cancer. To improve medical care of these patients, we examined the oncological outcomes in men with prostate cancer and a cancer history.

Patients And Methods: We retrospectively analyzed data from 25,422 prostate cancer patients, who underwent a radical prostatectomy between 1992 and 2016. Patients with other malignancies were identified using medical records and self-administrated questionnaires. Cox regression and Kaplan Meier analysis of a propensity score-matched patient cohort were performed to examine biochemical recurrence-free survival, metastasis-free survival, overall survival and prostate cancer-specific survival. Competing risk analysis was used to estimate other-cause mortality, other cancer-specific mortality, and prostate cancer-specific mortality. Statistical analysis was performed using R.

Results: Of all patients, 6.4% were diagnosed with other malignancy prior to radical prostatectomy. Patients with tumor history were older (median: 66 years vs. 64 years., P< 0,001) and showed a higher tumor volume (median: 4.0 ml vs. 3.6 ml, P = 0.02) than patients without. The risk of biochemical recurrence and metastasis development after radical prostatectomy was similar. All-cause mortality was significantly increased (hazard ratio 2.0; 95% confidence interval 1.7-2.4), while prostate cancer-specific mortality was lower (hazard ratio 0.4; 95% confidence interval 0.23-0.87) in patients with additional malignancy. In a propensity score-matched cohort overall survival was significantly adverse (P< 0.001) and prostate cancer-specific survival was higher (P= 0.003) in patients with other malignancy prior to surgery.

Conclusion: A higher other-cause mortality in men with tumor history should be concerned in the decision-making for medical care of prostate cancer patients in favor of reserved care strategies.
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http://dx.doi.org/10.1016/j.urolonc.2019.04.007DOI Listing
September 2019

Deep Learning for Real-time, Automatic, and Scanner-adapted Prostate (Zone) Segmentation of Transrectal Ultrasound, for Example, Magnetic Resonance Imaging-transrectal Ultrasound Fusion Prostate Biopsy.

Eur Urol Focus 2021 Jan 23;7(1):78-85. Epub 2019 Apr 23.

Laboratory of Biomedical Diagnostics, Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.

Background: Although recent advances in multiparametric magnetic resonance imaging (MRI) led to an increase in MRI-transrectal ultrasound (TRUS) fusion prostate biopsies, these are time consuming, laborious, and costly. Introduction of deep-learning approach would improve prostate segmentation.

Objective: To exploit deep learning to perform automatic, real-time prostate (zone) segmentation on TRUS images from different scanners.

Design, Setting, And Participants: Three datasets with TRUS images were collected at different institutions, using an iU22 (Philips Healthcare, Bothell, WA, USA), a Pro Focus 2202a (BK Medical), and an Aixplorer (SuperSonic Imagine, Aix-en-Provence, France) ultrasound scanner. The datasets contained 436 images from 181 men.

Outcome Measurements And Statistical Analysis: Manual delineations from an expert panel were used as ground truth. The (zonal) segmentation performance was evaluated in terms of the pixel-wise accuracy, Jaccard index, and Hausdorff distance.

Results And Limitations: The developed deep-learning approach was demonstrated to significantly improve prostate segmentation compared with a conventional automated technique, reaching median accuracy of 98% (95% confidence interval 95-99%), a Jaccard index of 0.93 (0.80-0.96), and a Hausdorff distance of 3.0 (1.3-8.7) mm. Zonal segmentation yielded pixel-wise accuracy of 97% (95-99%) and 98% (96-99%) for the peripheral and transition zones, respectively. Supervised domain adaptation resulted in retainment of high performance when applied to images from different ultrasound scanners (p > 0.05). Moreover, the algorithm's assessment of its own segmentation performance showed a strong correlation with the actual segmentation performance (Pearson's correlation 0.72, p < 0.001), indicating that possible incorrect segmentations can be identified swiftly.

Conclusions: Fusion-guided prostate biopsies, targeting suspicious lesions on MRI using TRUS are increasingly performed. The requirement for (semi)manual prostate delineation places a substantial burden on clinicians. Deep learning provides a means for fast and accurate (zonal) prostate segmentation of TRUS images that translates to different scanners.

Patient Summary: Artificial intelligence for automatic delineation of the prostate on ultrasound was shown to be reliable and applicable to different scanners. This method can, for example, be applied to speed up, and possibly improve, guided prostate biopsies using magnetic resonance imaging-transrectal ultrasound fusion.
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http://dx.doi.org/10.1016/j.euf.2019.04.009DOI Listing
January 2021

The Rising Star for Early Recurrent Cancer is Modern Imaging. But is it a Real Game Changer?

Authors:
Georg Salomon

Eur Urol Oncol 2019 02 11;2(1):77-78. Epub 2019 Jan 11.

Martini Clinic, Prostate Cancer Centre, University Medical Centre Eppendorf, Hamburg, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.euo.2018.12.009DOI Listing
February 2019

A comparative study of robot-assisted and open radical prostatectomy in 10 790 men treated by highly trained surgeons for both procedures.

BJU Int 2019 06 12;123(6):1031-1040. Epub 2019 Apr 12.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Objective: To compare oncological, functional and surgical outcomes of open retropubic radical prostatectomy (ORP) vs robot-assisted laparoscopic radical prostatectomy (RARP).

Patients And Methods: We identified 10 790 consecutive treated patients within our prospective database (2008-2016) who underwent either ORP (7007 patients) or RARP (3783). All procedures were performed by seven highly trained surgeons performing both surgical approaches regularly. Oncological (48-month biochemical recurrence [BCR] rate), functional (urinary continence, erectile function), and surgical outcomes (rate of nerve-sparing [NS] procedures, lymph node yield, surgical margin [SM] status, length of hospital stay [LOS], operation time, blood loss, transfusion rate, time to catheter removal) were assessed. Kaplan-Meier, multivariable Cox and logistic regression models were used to test for BCR and functional outcome differences.

Results: No statistically significant difference regarding oncological outcome distinguished between ORP vs RARP. For functional outcomes, the 1-week continence rates were higher in the ORP group (25.8% vs 21.8%, P < 0.001). At 3 months, no statistically significant differences were observed. At 12 months, continence rates were modestly higher in the RARP group (90.3% vs 88.8%, P = 0.01). This effect was no longer observed after stratification for age-groups. The 12-month potency rates were similar in ORP vs RARP (80.3% vs 83.6%, P = 0.33). For surgical outcomes, there was no significant difference in the rates of NS procedures, lymph node yield, SM status, and LOS. Conversely, operation time was shorter in ORP, and blood loss, transfusion rates and time to catheter removal were significantly lower in RARP.

Conclusions: Both surgical approaches, performed in a high-volume centre by the same surgeons, achieve excellent, comparable oncological and functional outcomes. However, a modest advantage for RARP for surgical outcomes was observed, most likely attributable to its minimally invasive nature, and better teaching capabilities. Consequently, more than the surgical approach itself, the well-trained surgeon remains the most important factor to achieve satisfactory outcomes.
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http://dx.doi.org/10.1111/bju.14760DOI Listing
June 2019

Impact of the estimated blood loss during radical prostatectomy on functional outcomes.

Urol Oncol 2019 05 8;37(5):298.e11-298.e17. Epub 2019 Mar 8.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Objective: To investigate the effect of the estimated blood loss (BL) during radical prostatectomy (RP) for prostate cancer (CaP) on functional outcomes. We hypothesized that the estimated BL during RP for clinically localized CaP does not affect the functional outcomes.

Materials And Methods: Patients who underwent open RP (ORP) or robotic-assisted laparoscopic RP (RALP) were identified. BL was stratified into low, medium and high: ≤500vs. >500 to 1000vs. >1,000ml for ORP and ≤150vs. >150 to 400vs. >400ml for RALP. Multivariable logistic regression models (MLRM) tested the effect of BL on functional outcomes.

Results: About 6,279 consecutive patients with ORP (2008-2015) and 2,720 patients with RALP (2009-2015) were identified. Low, medium, and high BL was recorded in 31.4vs. 45.7vs. 22.9% for ORP and in 39.8vs. 45.2vs.15.0% for RALP. MLRM predicting potency revealed that high BL was an independent predictor for erectile dysfunction: Odds ratios (OR) were 0.50 (P = 0.03) and 0.52 (P = 0.04) for ORP and RALP, respectively. MRLM predicting continence in ORP revealed that high BL was an independent predictor for 7-days and mid-term: ORs were 0.80 (P = 0.04) and 0.66 (P = 0.002). Moreover, high BL was an independent predictor for 7-days continence in RALP: OR were 0.68 (P = 0.009).

Conclusion: CaP patients who sustain higher BL during RP showed worse functional outcomes. High BL during ORP or RALP represented an independent predictor of erectile dysfunction and incontinence after surgery. However, the effect of high BL on the continence was temporarily and not present at 1 year after surgery in ORP and after 3 months in RALP.
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http://dx.doi.org/10.1016/j.urolonc.2019.01.006DOI Listing
May 2019

Future of focal therapy for the treatment of prostate cancer- european section of urotechnology (ESUT) position.

Arch Esp Urol 2019 Mar;72(2):167-173

Department of Urology. La Paz University Hospital. Madrid. Spain. Instituto de Investigación Hospital Universitario La Paz (IdiPAZ). Madrid. Spain.

Introduction: Focal therapy (FT) is a treatment option for prostate cancer (PCa), which offers the possibility of an effective therapy in selected patients who have the localized disease, with a significant reduction in treatment related morbidity. Based on the current status of FT, our objective was to determine the most appropriate strategy to improve patient management.

Materials And Methods: A literature review was done performed through the PubMed database and focused on the following topics: localised prostate cancer,MRI, prostate biopsies, ablative therapy and focal therapy.

Results: Indications for FT were mainly patients with a localised PCa, a single lesion at Gleason score 7 (3+4) (Grade group 2) favourable in size. Precise identification of the tumour, currently based on multiparametric MRI data and targeted biopsy, was the cornerstone of FT success. New imaging modalities such as PET/MRI and multiparametric ultrasound have proven to be effectivein detecting and targeting the tumour. Several energy sources were reported for an effective tissue ablation. Non-thermal option should be investigated to further limit the risk of side effects with the same cancer control.

Conclusion: Focal therapy is a new option in the armamentarium of PCa. Technological improvements and the development of novel energy sources should make it possible to treat lesions with even greater precision, while limiting the risk of side effects. In the future, we should probably be able to effectively expand the indications of this technique to include more aggressive tumours.
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March 2019

Persistent Prostate-Specific Antigen After Radical Prostatectomy and Its Impact on Oncologic Outcomes.

Eur Urol 2019 07 14;76(1):106-114. Epub 2019 Feb 14.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Background: Persistent prostate-specific antigen (PSA) represents a poor prognostic factor for recurrence after radical prostatectomy (RP).

Objective: To investigate the impact of persistent PSA at 6wk after RP on long-term oncologic outcomes and to assess patient characteristics associated with persistent PSA.

Design, Setting, And Participants: Within a high-volume center database we identified patients who harbored persistent (≥0.1ng/ml) versus undetectable PSA (<0.1ng/ml) at 6wk after RP. Patients with neo- and/or adjuvant androgen-deprivation therapy (ADT) were excluded.

Outcome Measurements And Statistical Analysis: Logistic regression models tested for prediction of persistent PSA. Kaplan-Meier analyses and Cox regression models tested the effect of persistent PSA on metastasis-free survival (MFS), overall survival (OS), and cancer-specific survival (CSS) rates. Propensity score matching (PSM) was performed to test the impact of salvage radiotherapy (SRT) on OS and CSS in patients with persistent PSA.

Results And Limitations: Of 11 604 identified patients, 8.8% (n=1025) harbored persistent PSA. At 15yr after RP, MFS, OS, and CSS were 53.0% versus 93.2% (p<0.001), 64.7% versus 81.2% (p<0.001), and 75.5% versus 96.2% (p<0.001) for persistent versus undetectable PSA, respectively. In multivariable Cox regression models, persistent PSA represented an independent predictor for metastasis (hazard ratio [HR]: 3.59, p<0.001), death (HR: 1.86, p<0.001), and cancer-specific death (HR: 3.15, p<0.001). SRT was associated with improved OS (HR: 0.37, p=0.02) and CSS (HR: 0.12, p<0.01) after 1:1 PSM. Main limitation is missing data on postoperative PSA and duration of salvage ADT.

Conclusions: Persistent PSA is associated with worse oncologic outcome after RP, namely, metastasis, death, and cancer-specific death. In patients with persistent PSA, SRT resulted in improved OS and CSS.

Patient Summary: We assessed the impact of persistent prostate-specific antigen (PSA) at 6wk after radical prostatectomy on oncologic outcomes. Early persistent PSA was associated with worse metastasis-free survival, overall survival, and cancer-specific survival. Salvage radiotherapy may result in a survival benefit in well-selected patients.
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http://dx.doi.org/10.1016/j.eururo.2019.01.048DOI Listing
July 2019

Perioperative management of direct oral anticoagulants in patients undergoing radical prostatectomy: results of a prospective assessment.

World J Urol 2019 Dec 6;37(12):2657-2662. Epub 2019 Feb 6.

Martini-Clinic, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.

Introduction And Objectives: In the perioperative setting, temporary interruption of direct oral anticoagulants (DOACs) is recommended. However, the safety of these recommendations is based on non-urological surgical experiences. Our objective was to verify the safety of these recommendations in patients undergoing radical prostatectomy (RP).

Materials And Methods: Patients regularly receiving a DOAC and scheduled for RP at our institution were prospectively assessed. DOAC intake was usually stopped 48 h before surgery without any preoperative bridging therapy. Postoperatively, patients received risk-adapted low-molecular weight heparin (LMWH). On the third day after unremarkable RP, DOAC intake was restarted and the administration of LMWH was stopped. We assessed perioperative outcomes and 30-day morbidity.

Results: Thirty-two consecutive patients receiving DOAC underwent RP at our institution between 12/2017 and 07/2018. Time of surgery (median, 177 min) and intraoperative blood loss (median, 500 mL) were unremarkable. DOACs were restarted on the third postoperative day in 30 patients (94%). No patient had a significant hemoglobin level reduction after DOAC restart. Overall, 28% of patients experienced complications within 30 days after surgery. Most of which were minor (Clavien ≤ 2), three patients (9%), however, had Clavien ≥ 3 complications.

Conclusion: Our report is the first to prospectively assess current guideline recommendations regarding DOAC restarting after major urological surgery. RP can safely be performed, if DOACs are correctly paused before surgery. Moreover, in case of an uneventful postoperative clinical course, DOACs can be safely restarted on the third postoperative day. A 9% Clavien ≥ 3 30-day morbidity warrants attention and should be further explored in future studies.
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http://dx.doi.org/10.1007/s00345-019-02668-zDOI Listing
December 2019

Radical prostatectomy after previous TUR-P: Oncological, surgical, and functional outcomes.

Urol Oncol 2018 12 12;36(12):527.e21-527.e28. Epub 2018 Nov 12.

Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Objectives: To examine oncological, surgical, and functional outcomes of radical prostatectomy (RP) in patients with history of transurethral resection of the prostate (TUR-P).

Materials And Methods: Retrospective analysis of 18,681 RP-patients including 470 patients with previous TUR-P at a single institution (2002-2015). Kaplan-Meier as well as multivariable Cox and logistic regression analyses compared surgical, oncological, and functional outcomes between TUR-P and non-TUR-P patients after propensity score matching (nearest neighbor in a 1:3 fashion).

Results: After propensity score adjustment, pathological and surgical results were similar between both groups. Specifically, rates of positive surgical margins and nerve-sparing (NS) procedure did not differ between groups (positive surgical margins: 18.5% vs. 17.2%, P = 0.7; nerve-sparing: 89.4% vs. 91.6%, P = 0.5). In addition, there was no difference in mean operating room time (185 vs. 184 minutes, P = 0.6), blood loss (710 vs. 666 ml, P = 0.1), and catheterization time (12 days, P = 0.3). In multivariable analyses, TUR-P patients did not exhibit higher risk of biochemical recurrence, metastatic progression, or mortality (all P > 0.05). However, TUR-P patients exhibited higher risk for urinary incontinence at third month (OR: 1.47; 95% confidence interval [CI] 1.01-2.12, P = 0.04) and first year (OR: 2.06; 95% CI 1.23-3.42, P = 0.006) and worse 1-year erectile function recovery (OR: 0.48; 95% CI 0.27-0.86, P = 0.02).

Conclusions: This large series of TUR-P RP patients demonstrated that RP could be safely performed in patients with history of TUR-P without compromising oncological results. However, functional outcomes were worse for patients with previous TUR-P.
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http://dx.doi.org/10.1016/j.urolonc.2018.08.010DOI Listing
December 2018

Multiparametric ultrasound: evaluation of greyscale, shear wave elastography and contrast-enhanced ultrasound for prostate cancer detection and localization in correlation to radical prostatectomy specimens.

BMC Urol 2018 Nov 8;18(1):98. Epub 2018 Nov 8.

Martini Clinic, Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Background: The diagnostic pathway for prostate cancer (PCa) is advancing towards an imaging-driven approach. Multiparametric magnetic resonance imaging, although increasingly used, has not shown sufficient accuracy to replace biopsy for now. The introduction of new ultrasound (US) modalities, such as quantitative contrast-enhanced US (CEUS) and shear wave elastography (SWE), shows promise but is not evidenced by sufficient high quality studies, especially for the combination of different US modalities. The primary objective of this study is to determine the individual and complementary diagnostic performance of greyscale US (GS), SWE, CEUS and their combination, multiparametric ultrasound (mpUS), for the detection and localization of PCa by comparison with corresponding histopathology.

Methods/design: In this prospective clinical trial, US imaging consisting of GS, SWE and CEUS with quantitative mapping on 3 prostate imaging planes (base, mid and apex) will be performed in 50 patients with biopsy-proven PCa before planned radical prostatectomy using a clinical ultrasound scanner. All US imaging will be evaluated by US readers, scoring the four quadrants of each imaging plane for the likelihood of significant PCa based on a 1 to 5 Likert Scale. Following resection, PCa tumour foci will be identified, graded and attributed to the imaging-derived quadrants in each prostate plane for all prostatectomy specimens. Primary outcome measure will be the sensitivity, specificity, negative predictive value and positive predictive value of each US modality and mpUS to detect and localize significant PCa evaluated for different Likert Scale thresholds using receiver operating characteristics curve analyses.

Discussion: In the evaluation of new PCa imaging modalities, a structured comparison with gold standard radical prostatectomy specimens is essential as first step. This trial is the first to combine the most promising ultrasound modalities into mpUS. It complies with the IDEAL stage 2b recommendations and will be an important step towards the evaluation of mpUS as a possible option for accurate detection and localization of PCa.

Trial Registration: The study protocol for multiparametric ultrasound was prospectively registered on Clinicaltrials.gov on 14 March 2017 with the registry name 'Multiparametric Ultrasound-Study for the Detection of Prostate Cancer' and trial registration number NCT03091231.
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http://dx.doi.org/10.1186/s12894-018-0409-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225621PMC
November 2018

Radical Prostatectomy after Vascular Targeted Photodynamic Therapy with Padeliporfin: Feasibility, and Early and Intermediate Results.

J Urol 2019 02;201(2):315-321

Department of Urology, Lyon Sud University Hospital, Lyon.

Purpose: Vascular targeted photodynamic therapy with TOOKAD® is a new therapeutic option for localized prostate cancer management. The objectives of this study were to assess the feasibility of radical prostatectomy after vascular targeted photodynamic therapy and describe functional and oncologic outcomes.

Materials And Methods: We retrospectively included in study 45 patients who underwent salvage radical prostatectomy after vascular targeted photodynamic therapy for recurrent prostate cancer at a total of 14 surgical centers in Europe between October 2008 and March 2017. Of the 42 radical prostatectomies performed 16 were robot-assisted, 6 were laparoscopic and 20 were open surgery. Primary end points were morbidity and technical difficulties. Secondary end points were early and intermediate postoperative functional and oncologic outcomes.

Results: Median operative time was 180 minutes (IQR 150-223). Median blood loss was 200 ml (IQR 155-363). According to the surgeons the surgery was easy in 29 patients (69%) and difficult in 13 (31%). Nerve sparing was feasible in 14 patients (33%). Five postoperative complications (12%) were found, including 2 Clavien I, 2 Clavien II and 1 Clavien IIIB complications. Of the cases 13 (31%) were pT3 and 21 (50%) were pT2c. Surgical margins were positive in 13 patients (31%). Prostate specific antigen was undetectable at 6 to 12 months in 37 patients (88%). Nine patients underwent complementary radiotherapy. Four patients had final prostate specific antigen greater than 0.2 ng/ml at a median followup of 23 months (IQR 12-36). At 1 year 27 patients (64%) were completely continent (no pads) and 10 (24%) had low incontinence (1 pad). Four patients (11%) recovered potency without treatment and 23 (64%) recovered potency with appropriate treatment.

Conclusions: Salvage radical prostatectomy after vascular targeted photodynamic therapy treatment was feasible and safe without difficulty for most of the surgeons.
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http://dx.doi.org/10.1016/j.juro.2018.08.084DOI Listing
February 2019

Antimicrobial Lubricant Did Not Reduce Infection Rate in Transrectal Biopsy Patients in a Large Randomized Trial Due to Low Complication Rates.

Eur Urol Focus 2019 11 23;5(6):992-997. Epub 2018 Jun 23.

Martini-Clinic, Prostate Cancer Centre, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany. Electronic address:

Background: Transrectal prostate biopsy (pbx) is the most frequent outpatient procedure in the urological field. Septic complications are a major health issue.

Objective: To evaluate complication rates with or without an antimicrobial lubricant.

Design, Setting, And Participants: A total of 1000 patients received pbx between 2013 and 2015. Information about complications was collected by a 3-wk questionnaire. Return rate was 73.2% (n=732).

Intervention: Randomization for pbx with the instillation of an antimicrobial lubricant (intervention group, n=385) or the standard lubricant (control group, n=347) was performed.

Outcome Measurements And Statistical Analysis: Multivariable analyses assessed the association between infectious complications at biopsy and use of an antimicrobial lubricant, International Prostate Symptom Score (IPSS), history of urogenitourinary infections, and several other confounders.

Results And Limitations: The use of an antimicrobial lubricant did not reduce infection rate. Overall complication rate was very low. Of all patients, 69.3% described the procedure as pain free. Fever ≥38.5°C was reported in overall 1.9% of patients. Urinary retention with catheterization occurred in 3.1%. Most common complications were hematospermia (47.4%), macrohematuria (23.8%), and rectal bleeding (7.4%). Readmission rate was 1% (n=7). In multivariable analyses, IPSS and previous infectious complications were associated with a higher risk of infectious complications. Our results stem from a large German single center and therefore are limited to this patient group.

Conclusions: No significant reduction was shown in infectious complications in the intervention group with the antimicrobial agent. Low incidence of those complications may be the underlying cause. Severe morbidity at pbx is uncommon. Specifically, the rate of infection was very low.

Patient Summary: Severe complications at prostate biopsy are rare. Among participants, 69.3% had no pain. Fever was rare (1.9% of patients). Voiding issues with catheterization occurred in 3.1%. Most common complications were blood in the semen (47.4%), urine (23.8%), or stool (7.4%). Men with voiding issues or previous infectious complications had a higher risk of infectious complications.
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http://dx.doi.org/10.1016/j.euf.2018.06.005DOI Listing
November 2019

Marked Prognostic Impact of Minimal Lymphatic Tumor Spread in Prostate Cancer.

Eur Urol 2018 09 13;74(3):376-386. Epub 2018 Jun 13.

Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Section for Translational Prostate Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Nodal metastasis (N1) is a strong prognostic parameter in prostate cancer; however, lymph node evaluation is always incomplete.

Objective: To study the prognostic value of lymphatic invasion (L1) and whether it might complement or even replace lymph node analysis in clinical practice.

Design, Setting, And Participants: Retrospective analysis of pathological and clinical data from 14 528 consecutive patients.

Intervention: Radical prostatectomy.

Outcome Measurements And Statistical Analysis: The impact of L1 and N1 on patient prognosis was measured with time to biochemical recurrence as the primary endpoint.

Results And Limitations: Nodal metastases were found in 1602 (12%) of 13 070 patients with lymph node dissection. L1 was seen in 2027 of 14 528 patients (14%) for whom lymphatic vessels had been visualized by immunohistochemistry. N1 and L1 continuously increased with unfavorable Gleason grade, advanced pT stage, and preoperative prostate-specific antigen (PSA) values (p<0.0001 each). N1 was found in 4.3% of 12 501 L0 and in 41% of 2027 L1 carcinomas (p<0.0001). L1 was seen in 11% of 9868 N0 and in 61% of 1360 N1 carcinomas (p<0.0001). Both N1 and L1 were linked to PSA recurrence (p<0.0001 each). This was also true for 17 patients with isolated tumor cells (ie, <200 unequivocal cancer cells without invasive growth) and 193 metastases ≤1mm. Combined analysis of N and L status showed that L1 had no prognostic effect in N1 patients but L1 was strikingly linked to PSA recurrence in N0 patients. N0L1 patients showed a similar outcome as N1 patients.

Conclusions: Analysis of lymphatic invasion provides comparable prognostic information than lymph node analysis. Even minimal involvement of the lymphatic system has pivotal prognostic impact in prostate cancer. Thus, a thorough search for lymphatic involvement helps to identify more patients with an increased risk for disease recurrence.

Patient Summary: Already minimal amounts of tumor cells inside the lymph nodes or intraprostatic lymphatic vessels have a severe impact on patient prognosis.
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http://dx.doi.org/10.1016/j.eururo.2018.05.034DOI Listing
September 2018

Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System).

Eur Urol 2018 09 10;74(3):294-306. Epub 2018 May 10.

Academic Urology Unit, University of Sheffield, Sheffield, UK.

Context: Management of bladder cancer (BC) is primarily driven by stage, grade, and biological potential. Knowledge of each is derived using clinical, histopathological, and radiological investigations. This multimodal approach reduces the risk of error from one particular test, but may present a staging dilemma when results conflict. Multiparametric magnetic resonance imaging (mpMRI) may improve patient care through imaging of the bladder with better resolution of the tissue planes than computed tomography and without radiation exposure.

Objective: To define a standardized approach to imaging and reporting mpMRI for BC, by developing a VI-RADS score.

Evidence Acquisition: We created VI-RADS (Vesical Imaging-Reporting And Data System) through consensus using existing literature.

Evidence Synthesis: We describe standard imaging protocols and reporting criteria (including size, location, multiplicity, and morphology) for bladder mpMRI. We propose a five-point VI-RADS score, derived using T2-weighted MRI, diffusion-weighted imaging, and dynamic contrast enhancement, which suggests the risks of muscle invasion. We include sample images used to understand VI-RADS.

Conclusions: We hope that VI-RADS will standardize reporting, facilitate comparisons between patients, and in future years, will be tested and refined if necessary. While we do not advocate mpMRI for all patients with BC, this imaging may compliment pathology or reduce radiation-based imaging. Bladder mpMRI may be most useful in patients with non-muscle-invasive cancers, in expediting radical treatment or for determining response to bladder-sparing approaches.

Patient Summary: Magnetic resonance imaging (MRI) scans for bladder cancer are becoming more common and may provide accurate information that helps improve patient care. Here, we describe a standardized reporting criterion for bladder MRI. This should improve communication between doctors and allow better comparisons between patients.
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http://dx.doi.org/10.1016/j.eururo.2018.04.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690492PMC
September 2018